An Idea Factory for Pathology Informatics and the Clinical Laboratory. Presented by the Pathology Education Consortium (PEC).

15 posts from September 2012

I can't say that anyone will be shocked by the news that HCA seems to have signed a big contract with Epic. I had been hearing that this very large health system was reviewing their long-standing relationship with Meditech. Mr. HIstalk commented about an Epic pilot at an HCA hospital last December (see: Monday Morning Update 12/19/11). It stands to reason that this large health system would take a serious look at Epic. Here's the December HIStalk item:

Q. From EpicNews: “Re: HCA. Any rumors about HCA signing with Epic?”

A. I’ve mentioned here several times that HCA is putting up an Epic pilot as they choose between that option and upgrading Meditech. I haven’t heard anything more than that, although a couple of less well-placed rumors seem to think Epic is the likely choice (I’m guessing that’s due to Epic’s track record rather than any real insider knowledge.)

I have now been informed by a couple of good sources that HCA has signed a $1B plus deal with Epic for some 173 hospitals and 200 free-standing surgical centers with installation phased over the next ten years (see: Hospital Corporation of America). The plan is also said to include deployment of Beaker, Epic's LIS, including surgical pathology. With regard to Beaker, this seems like very good fit because most of the HCA sites are smaller, less complex facilities that are currently using the Meditech LIS. Most would not consider this latter a best-of-breed system so the bar won't be set too high for Beaker.

I had posted a previous note in February, 2011, quoting older Epic-supplied information that Epic had 51 employees working on Beaker (see: Details about Epic's Beaker LIS, Supplied by the Company). I am now hearing rumors that the company is adding personnel to the Epic development team as fast as they can find them including some who have worked on LISs for best-of-breed vendors. The company will soon need to satisfy a number of fastidious, demanding pathology departments regarding Beaker functionality.

In a recent note, I speculated that Epic, having created what now looks like a dominant position in large hospitals and academic medical centers, would now turn to mid-size hospitals for continuing growth (see: Epic Deemed Unbeatable by HIStalk in the Large Hospital EMR Market). If the news about the HCA deal is true, Epic should be able to leverage this experience to expand its presence in the mid-hospital segment.

Much of the discussion and debate around bringing higher education online has touched upon the implications of putting course material online versus in-person teaching. There are many questions floating around, such as how will students benefit from online classes if course credit isn’t given? What does the future hold for traditional brick and mortar institutions? While these points are important and not to be dismissed, there is a key issue that education pundits are often overlooking: the issue of access. For millions of people around the world, the choice is not between attending traditional university and online courses, between seeing a lecture in person and watching one online....[F]or many students, the choice is between online education and no education at all....Needless to say, few countries can offer university-level education for free. But as Internet access improves globally, online education is becoming a very real solution for students who might not have the prior experience needed to enroll in local colleges, who can’t afford tuition, whose lifestyle does not permit them the leisure to attend classes in person, or or who can’t commute to schools far away from home....But giving someone the opportunity to take courses taught by top-tier universities and professors strikes at the core of what learning is all about — fostering personal growth, creating career opportunities, spreading knowledge of important topics, and developing bonds with other students....While technically many Americans continue to have access to higher education, that access is dependent on student loans.

The burgeoning debt caused by these loans is becoming unsustainable both for the individual and for society at large....[S]ince 1985, the cost of higher education has gone up 559%, almost double the rate of the rising cost of health care. We have to start looking into ways to reduce the cost of higher education. Technology and online learning specifically, if thoughtfully employed, could reduce these costs, and allow our college students to graduate without being shackled to a gross amount of debt. Not everything that happens in an in-person classroom is currently replicated with an online course, and perhaps the experience will never be the quite the same. But there are new opportunities that online learning opens up that would have never been possible without this technology. We have the incredible opportunity to provide access to education to millions worldwide, to allow students to graduate without enormous debt, while at the same time allowing us to rethink and enrich the learning experience with the participation of students from almost every country in the world. We have the incredible opportunity to make education what it should be: a fundamental human right.

I believe that much of the opposition to massive online open courses (MOOCs) is coming from conservative faculty members who are resistant to change. Nevertheless, the obvious success of a number of online educational initiatives will ultimately drown out the protests of these naysayers. For your own exploration of online opportunities, here are links to the web sites of four difference companies (see: Massive open online course):

Coursera - A VC-funded company founded by computer science professors Andrew Ng and Daphne Koller from Stanford University, located in Mountain View, California.

edX - A non-profit led by the Massachusetts Institute of Technology, Harvard University, and the University of California, Berkeley, that offers university-level courses from a wide range of disciplines online to a worldwide audience at no charge.

Khan Academy - A non-profit educational organization created in 2006 by Indo-Bangladeshi American educator Salman Khan.

In subsequent notes, I will begin to speculate about how MOOCs might be used for both undergraduate and continuing medical education.

It’s official, Big Data is the flavor of the month....According to McKinsey Global Institute, “Big Data refers to datasets whose size is beyond the ability of typical database software tools to capture, store, manage and analyze.” IT guru, Buck Woody, says, “Big data is the data that you aren’t able to process and use quickly enough with the technology you have now.” But Big Data is more than “lots of data.” It goes beyond quantity and speaks to the challenges of velocity and diversity. In today’s age of digital media and channels, vast amounts and types of data are coming at us so fast and from every online and offline direction. Big Data refers to the ability (or inability) to effectively deal with all these aspects of consumer information....

Substantial changes in technology have given us the opportunity to process the mounds of data we are generating and actually do something with it.....Twenty-five years ago, most data systems processed flat files in mainframe environments. ....The relational database represented a fundamental shift from the mainframe, storing data more effectively and efficiently by “remembering,” while a mainframe “processes and forgets.” Now, these relational databases have gotten even more sophisticated. As the internet created new industries..., companies have begun dealing with data that’s not only real-time but also unstructured in nature. Consider Google, whose “data” is effectively the internet – they basically download and index the internet as a business. This data change forced new technology advancements and caused a paradigm shift in data management. Enter things like NoSQL...environments to the mix, and suddenly, we’re in the era of Big Data. But through the evolution of mainframe to database to NoSQL, have we really created competitive advantage for companies?....

The digitization of – well, everything – is creating “data” at an unprecedented rate. And data is only valuable when it can be converted to information and understood and rationalized. With Big Data, the vast majority of the data is ‘information poor,’ (i.e., worthless). As the data grows and changes, how has analytics evolved to find meaning in a growing sea of data noise? Twenty years ago, we used predictive modeling to forecast direct mail responsiveness. Back then, we had to significantly “sample down” the data so our mainframes and desktop computers could process statistical regression models in a timely manner. But with today’s advancements in technology, our ability to process all the data has changed dramatically. I believe the first main difference with Big Data is that we no longer have to rely on sampling to determine the likely outcome of a population. Today’s technology is vast enough to process all the data we couldn’t study before.

So, what's the relevance of all of this for healthcare? Well, for one thing, hospitals sit on a mountain of data. The labs churn out much of it. One might speculate that healthcare would provide a golden opportunity to test some of the basic concepts in this emerging field. However, David Kibbe and Vince Kuraitis suggest in a blog note that this would be premature (see: The Power of Small). Another article continued the discussion (see: Think Small Data Before Big Data, Healthcare Gurus Argue). Below is an excerpt from the latter article:

Kibbe and Kuraitis assert that it's premature and unnecessary to use big data in patient care. Instead, they maintain, providers should use "relatively low tech, high touch, data-driven interventions" to improve care management. They suggest establishing electronic registries to identify and manage high-risk, high-cost patients. Electronic health records certified for Meaningful Use stage 1, they note, can generate clinical summaries known as continuity of care documents (CCDs) that providers can use to export data to those registries....."Simple data mining" of registries, they point out, has been used successfully to:

This is a great move by Mt. Sinai. Just as the article said, the US will aid with the physical diagnosis skills of the students. And Dr. Friedman is right in stating that the portable ultrasound devices will help students learn anatomy. Not just the anatomy in texts or cadavers, but real...breathing, moving, and living anatomy.

There have been recent studies about this same topic this including this and this. This first link is to an abstract and the second is to the full article. Here's a portion of the latter authors' conclusion :

Based on our 4-year experience with an integrated ultrasound curriculum, it is clear that ultrasound can be successfully introduced across all 4 years of medical school. It has also been shown that students can readily learn focused ultrasound examinations well and that the students enjoy their ultrasound experience. They overwhelmingly report that ultrasound has enhanced their medical education.

At the present time, ultrasound imaging is dominated by radiologists and a few other categories of specialists (i.e., cardiologists, vascular surgeons) However, I feel that ultimately ultrasound will be best suited for "point of care" imaging of patients. Hopefully and in the near future, primary care physicians will be performing these procedures. Soon afterwards it will be the medics (already starting to do it) on the battlefields and the EMTs who are also on the front line of health care delivery.

In response to a question from a reader, Mr. HIStalk recently suggested that Epic was unbeatable in the large-hospital EMR market. He provides five reasons for his assertion (see: Monday Morning Update 9/17/12):

...I don’t think that Allscripts (or any other vendor, at the moment) can compete with Epic in the large-hospital inpatient clinical systems market. Reasons: (a) incomplete integration; (b) narrower product line; (c) lower customer satisfaction; (d) lack of momentum; (e) hospital consolidations favoring existing Epic customers; and (f) trying to disrupt the status quo with one hand firmly planted in Wall Street’s lap. It’s not the end of the world for Allscripts – 80% hospitals aren’t candidates for Epic but need a lower-priced, pre-packaged, hosted product, meaning the biggest companies to beat are Meditech, McKesson, Cerner, and Siemens. Struggling to compete against Epic in big-hospital accounts hasn’t hurt Cerner, which doesn’t bag a lot of fresh Millennium wins over Epic but still has turned its assets into a $12 billion company. If you want to score Epic vs. Allscripts without emotion or subjectivity, it’s easy – just watch the number of new sales, the total number of beds and EPs covered, and KLAS scores.

Let's examine the idea that Meditech, McKesson, Cerner, and Siemens are the "companies to beat" in the 80% of the hospitals that aren't currently a slam-dunk for Epic. By this is meant the mid-size, non-academic hospitals. I can easily argue both sides of this question. On the one hand, these hospitals tend to be quite independent and wary of IT initiatives that would draw them closer to the neighboring, larger facilities that may be running Epic. They often view these larger hospitals as competitors. I have previously speculated that Cerner was moving into this mid-tier market because of an inability to compete with Epic for the EMR business of larger hospitals. From this perspective, these companies would be favored by these hospitals.

However, there will be a new chapter in this narrative. What happens when the larger and academic hospital market converts almost totally to Epic? Where does Epic then turn in order to continue growing? Two options would appear to be to (1) sell its product to hospitals abroad which has proven to be a lucrative market for Cerner; (2) target those U.S. midsize hospitals which may have been encountering Epic sticker-shock. My hunch is that Epic will turn its gaze on the large number of mid-size facilities for its continuing growth. This is where Cerner has been driven by the Epic competition (see: Is Cerner Modifying Its EMR Business Model?).

First-year medical students at Mount Sinai School of Medicine will be the first in New York to be introduced to a digital-age ultrasound device that can visualize inside the body, and fit directly into the pockets of their brand new white coats. The visualization tool, made by GE Healthcare, is a handheld ultrasound device called Vscan, and is roughly the footprint of a smartphone. The Vscan houses innovative technology that can provide an immediate, non-invasive method to secure visual information from inside the body. A total of 72 pocket-sized devices will be provided for use in a research study and distributed to teams of first year medical school students that make up the 140-member Class of 2016. The objective of the study is to demonstrate that handheld imaging technology can contribute to medical education at all levels of instruction and learning.....“First year medical students traditionally learn about the human body by dissecting the cadavers and eventually by examining the patients, and the examination ranges from inspection and palpation to listening with the help of a stethoscope and interpreting the sounds of the heart, lungs and blood vessels,” says [the primary investigator] of this research study....“With handheld ultrasound, our medical students will have the ability to see live images of inside the body projected onto a handheld screen in real time. It’s an innovative educational concept that can modernize medical education.” In fact, [he] believes that imaging and specifically handheld devices will become an integral part of the physical examination. As part of the study, handheld ultrasound will be added to the curriculum of first year students....to augment their physical examination skills. Groups of four students will share the device as they learn about the capabilities of ultrasound

When I previously discussed the use of portable ultrasound devices by medical students, I primarily thought of the devices as diagnostic tools for detecting disease during physical exams. This article highlighted for me what is probably a more important goal for medical students: development of a better understanding of the normal anatomy of patients. Back in the day, such an understanding was gained during gross anatomy classes with the dissection of a cadaver. Some of this didactic work has now been replaced by the use of computerized gross anatomy programs. However, it seems to me that non-invasive visualization of organs in a living, breathing patient during a physical exam by students would be extremely useful.

It seems to me that budding surgeons benefit most from cadaver dissection. The majority of physicians in training, however, will and should be more concerned with issues such as the size of organs, their relationship to neighboring organs, the presence of fluids in body cavities, and lymphadenopathy. Ultrasound devices can provide information about all of these questions. The introduction of portable ultrasound devices into medical schools has not moved as quickly as I had initially anticipated but I am certainly enthusiastic about this current report. Perhaps the pace will pick up, particularly if companies like GE put them in the hands of student at very low cost. This will aid in the more general adoption of the technology.

If I attribute the reporting of others and manage to steer clear of proprietary intellectual property while making a cogent argument, then I can live to write another day. If, on the other hand, I manufacture or manipulate quotes or fail to process the work of others through my own thinking and writing, then the Web ...will find me out....Once spilled, news quickly becomes a commodity, so ideas...have very high value. That preciousness is part of why Jonah Lehrer, the ninja of neuroscience, became a highly prized collectible while still in his 20s....He is smarter than I will ever be, and has written three best sellers while being paid thousands of dollars for speaking engagements. The other difference? I never made up quotes, lied about it and resigned in disgrace, as Mr. Lehrer recently did....Because of a quirk of timing, the blogger-author-speaker’s troubles have been conflated with those of Fareed Zakaria, the television host-columnist-author....[T]here is a big difference between being a plagiarist...and being a fabulist. Ten days ago Mr. Zakaria, who has a show on CNN and columns in Time and The Washington Post, acknowledged plagiarizing content for a column in Time. He apologized, was suspended, and Time and CNN investigated whether there was a deeper problem and decided there was not. He was reinstated on Thursday. End of story. As for Mr. Lehrer, he was first found to have plagiarized himself, rerunning parts of his books and previous writings for different publications, which is an offense against his employers, not his readers. Then Michael C. Moynihan, writing in Tablet Magazine, found that Mr. Lehrer, in his book “Imagine,” had fabricated quotes from Bob Dylan, one of the most scrutinized cultural figures in the hemisphere. As the evidence mounted, Mr. Lehrer first dissembled to hide his transgressions and when that didn’t work, he resigned from The New Yorker....The self-cleaning tendencies of the Web got credit for unearthing the misconduct in the first place. Then again, the Web’s ferocious appetite for content — you are only as visible as your last post, as Clay Shirky recently said to me — probably had something to do with why Mr. Lehrer tried to feed the beast with retreads and half-baked work.

I few of the ideas in this article caught my attention. The first is what is referred to as the "self-cleaning tendencies of the web." Content of the web never disappears, it lends itself to amateur sleuthing when suspect, and is subject to echoic effects such that a minor slip by a celebrity like Jonah Lehrer can be publicized in a short time. And what was Lehrer's major slip? Probably fabricating a quote from a cultural icon like Bob Dylan. I suspect that he would not have gotten in as much trouble so quickly if he had fabricated a quote from Immanuel Kant.

But back to web-enabled plagiarism. I believe that the ease of cut-and-paste of content from the web (and also EMRs, by the way) facilitates a mentality that tolerates, if not encourages, copying. However, as a long-time blogger, I understand the rules of the game and imagine that readers may frequently quote bloggers without attribution. However, my personal goal for Lab Soft News is to stimulate discussion about lab and healthcare issues. I believe that this goal is far more important than correctness of authorship. On another level and as emphasized above, the web has an enormous appetite for content. Celebrity authors are merely trying to "feed the beast" on a daily basis with new content and mistakes do happen with the rapid turnaround required by web authorship.

Don't forget to participate in a webinar tomorrow entitled Technical Barriers to the Adoption of Digital Pathology. The time will be 11:00 AM - 12:00 PM EST. This event is the second in the Digital Pathology Association (DPA), Association of Pathology Informatics (API), and CAP Today's series of one-hour presentations focusing on the barriers to the adoption of digital pathology. The lectures tomorrow will feature Sean Costello, Head of Product Management, Digital Pathology, Leica Microsystems, and Kim Dickinson, MD, President-Elect of the DPA. It will be moderated by Robert McGonnagle, publisher of CAP Today. Registration for the event is required; non-DPA members can create a profile at the DPA web site.

Mr. HIStalk had a recent item discussing HIMSS with his "reform" solution for the organization appended at the end (see: News 9/12/12):

From David: “Re: Dr. Jayne’s comment on ‘educational session’ put on for members of Congress. As someone who used to put these on, these are simply a forum for making a lobbying pitch to lawmakers and Congressional staff under the guise of education. The ‘education’ is to get lawmakers to vote in the interests of the event’s corporate sponsors.”

[Mr. HIStalk response]: Sponsors listed include HIMSS, Ingenix, Allscripts, BCBSA, and a bunch of other companies, government contractors, and member organizations. It was the Washington schmoozing and complete surrender to its Diamond members that largely turned me against HIMSS as an organization that represents me as a non-profit hospital employee and dues-paying member instead of a piece of meat offered up for ogling by its conference exhibitors. I would rather see HIMSS split into two groups, one for providers only (like it almost was before the current regime got dollar signs in their eyes) and the other being the vendor trade association that HIMSS denies being despite ample similarities.

I need to emphasize here that exhibitors are absolutely essential for successful medical conferences: (1) they subsidize such events that can't be offered solely on the basis of registration fees; and (2) they educate registrants in the exhibitor areas about their product offerings. However, there needs to be a firewall between such exhibitors and the conference content. In short, the exhibitors shouldn't be able to influence the content or use the organization as a conduit to its members other than in the designated exhibitor spaces.

HIMSS will never split itself into two parts. The reason is that additional revenue is generated by providing access to its members through "educational sessions" and "meet-and-greet" events as described above. HIMSS uses its members to generate revenue. The members are the bait and you always keep your bait close to you when you go fishing. The bigger you are, the bigger you get.

Enthusiasm for both tablets and smart phones continue to rise with the PC ecosystem in decline. Some of the details of this shift were in a recent article (see: The Shift: as tablets surge, PCs lose):

Last week when Intel announced that it was going to miss its financial targets for rest of the year, it was another testament to the shift of computing from PCs to tablets. New research from JP Morgan only reaffirms the shift to tablets....Last week, Intel, the largest chip maker in the business, pre-announced that it would miss its already lowered estimates for the remainder of the year, mostly because of softening demand for its PC-focused chips. Intel blamed the macro-economic slowdown on softening corporate PC demand, a sluggish Europe and increasingly skittish growth economies like India and China. Intel’s announcement comes close on the heels of a similar warning from its rival, AMD. What gives Intel’s forecast a doomsday-like quality is the fact that it comes weeks before the launch of Microsoft’s newest operating system, Windows 8....So if Intel is experiencing softening demand for chips, then it is not hard to imagine Microsoft navigating choppy waters as well....JP Morgan’s research team pointed out that other suppliers to the PC ecosystem – hard disk drive makers — are going to suffer as well.The traditional PC ecosystem also has another challenge — competition for attention and dollars from cheaper, more sexy devices such as smartphones and tablets....JP Morgan’s Tablet forecast has the answer [about what this all of this means]:Our revised 2012 tablet revenue estimate is $57.7 billion, versus $52.8 billion previously. Our revised tablet unit estimate is 118.5 million, versus 106.8 million previously.

For me, all of this seems pretty clear as it applies to lab professionals including pathologists. It's also relevant for physicians and nurses. Any mobile physician will be drawn inexorably toward mobile computing devices -- tablets and smart phones. The choice between them will be made on the basis of how much screen real restate is required. Both devices can be used for relatively simple tasks such as reviewing patient history, making simple progress notes, or entering drug orders. Power computing will continue to be performed in offices using PCs and Macs. If supplied by the hospital or department for work, these will be commodity purchases with a restricted set of apps for reasons of security and easy maintenance. Also look for the availability of more powerful tablets that will rival the computing power of some PCs. You will be able to attach them to larger and more sophisticated keyboards for power computing tasks.

Apple has sold about 40 million iPads since 2010. Of the iPad owners McKinsey surveyed, it found that 62 percent never take their iPad outside their house. In other words, it’s being used as just another home computer, like a replacement laptop for tasks such as watching video or browsing the web. While the iPad is “finding its way into places in the home we didn’t have computing in the past,” the living room is where people use their iPad: 70 percent of usage takes place there. Said [an industry expert]: “The PC tried to get into the living room for 20 years. Well, it’s here.” The side effect of iPad owners finding their iPad good enough for certain computing tasks at home is a delay in plans to buy a new PC. You can see that in the slowly declining PC sales over the last few quarters: By the end of this year, IDC expects worldwide PC shipments will have grown a measly 2.8 percent compared to 2010.